Table 1 Main actors, original and modified roles, and influence in the allocation and management of Seguro Popular financial resources
Actor | Objective/iIncentives | Role in the system | Power | Policy responses | Source |
|---|---|---|---|---|---|
National Commission of the Health Social Protection Policy (considered in the guidelines and had the same role as originally intended) | Ensure that the policy achieves its desired goals | To manage financial resources and transfer them to the states Coordinate the operation Stewardship To evaluate the REPSS performance as well as the overall system. To support the accountability of funds | High but without legal capacity of sanctioning It can delay disbursement of funds, e.g., if financial reports are not received It cannot act if they detect mishandling of resources | -Adapted and modified the policy -Changed the definition of capitation from family to individual -Accepted the state’s 15 % financial share to be represented by previous investments -Introduced a cap on spending on medicines (30 %) and hiring (40 %) -Families belonging to III and IV deciles were exempted from pre-payment | |
State government treasury (not explicitly mentioned in the original guidelines but having a role) | Provide a mechanism for auditing the flow of funds | Receive funds from the National Commission and register them in the state’s financial system | High because of legal capacity to handle finances and sanctioning | -Kept funds as much as they can to obtain bank interests | |
State Ministry of Health (considered in the guidelines but its role changed) | Provide health services through its public network | Receive funds and allocate according to capitation | High, e.g., in terms of fund allocation according to their priorities and network since it substituted the original role of REPSS | -Kept REPSS inside its structure to keep hold of federal financial resources -Did not implement capitation but maintained historical budget due to lack of information and managerial capacity -Initially issued short staff contracts to reduce costs but under pressure had to extend contracts -Limited private sector purchasing of services | |
State Health Social Protection Regime (REPSS) (considered in the guidelines but changed its role) | Original: Purchasing of services from public and private in an equitable and efficient way Revised (except in one state): ensure the highest number of affiliates registered and reported to bring more funds to the state | Original: financial intermediary Affiliate new users Protect users’ rights Management of financial resources Purchasing of services, Accountable to state and federal authorities Revised (except in one state): Administering the funds from affiliating new people into the plan. Transfer this information to the National Commission To participate in the allocation of resources to public health units | Low power or influence in allocation of funds Their role shrunk over time by being absorbed by the state MOH Although they existed under the MOH, they became increasingly passive | -Increased number of affiliated families, e.g., by re-interpreting the guidelines to identify single member families, to increase the funds allocated to the state | |
National Workers Union (not considered in the guidelines but acquired an active role) | Represent the interests of unionized workers towards the employer | Negotiate the regularization of contracts. Monitor the process of regularization | High: Every regularized worker pays a 2 % fee of the value of the contract to receive protection from the union (contracts consumes between 40–60 % of the system’s total SP funds) | -Became active in the regularization of contracts process by negotiating with top federal players | |
Contracted workers (not considered in the guidelines but having active role) | Obtain contracts to provide services | Participate in the delivery of services to the SP affiliated population | Low: they did not put pressure to obtain better contracts | Became active in the regularization of contracts process by accepting new contracts negotiated by the union | [23] |
Pharmaceutical retailers (Not considered in the guidelines but having an active role) | Participate in bids and sell their products | Negotiate the selling price of medicines with each state | High: there are limited number of retailers and they lobby to agree on medicine pricing levels | -Depending on the state, retailers negotiated highly profitable contracts -Used their corporative and marketizing capacity to sell their products and to agree on drug prices used in bids | |
Pharmaceutical distributors (NEW) (not considered in the guidelines but acquired an active role) | Win the bid for distributing drugs within the state | Negotiate to win the bid | Low—as there is more competition | -Used different marketing strategies to win distribution bids and to convince the states that they could reduce allocation times despite the cost involved. | [23] |
State health bureaucracy (considered in the guidelines and had an active role) | As possible: -Use funds to cover its needs -Continue to function as before | Management of Seguro Popular funds at different levels and activities | High—in terms of flexibility to manage and spend funds | As initially no sanction system existed (before auditing started in 2009), some: 1. Bought medicines at high prices 2. Bought non-authorized goods 3. Contracted health workers without demonstrated competence | |
Health units (providers) (considered in the guidelines but had a passive role) | Provide health services according to population needs and their capacity | Receive resources and provide services to the affiliated population | No power as they do not receive any funds directly | -No incentive to change status quo—business as usual -Complained about not being heard or participate actively in the allocation process or decision—e.g., responding to the health challenges they face | |
Beneficiaries affiliated to Seguro Popular (considered in the guidelines and acquired an active role) | Original: Had the right to choose providers Current: In practice, cannot exert that right as they have to deal with limited number of providers (mostly public sector) | Recipients of health services contained in the package of benefits | Low but increasing—e.g., if they organize themselves to exert more pressure | -As they received information about their rights, they increasingly became more vocal in obtaining better services and medicines |